"It’s vital for tech firms to earn and maintain the trust of people we care for"

Dr. Vivian Lee, President of Health Platforms, Verily Life Sciences in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “It’s vital for tech firms to earn and maintain the trust of people we care for”

PP: [0:01:03] Hello again everyone, and welcome back to my podcast. It’s my great privilege and honor to introduce my special guest today, Dr. Vivian Lee, President of Health Platforms at Verily Life Sciences. Vivian, thank you so much for setting aside the time and welcome to the show.

VL: [0:01:11] Thanks so much, Paddy, it’s wonderful to be with you.

PP: [0:01:25] You’re most welcome. Can you tell us for the benefit of our listeners a little bit about Verily and its mission?

VL: [00:01:33] I joined Verily about two and a half years ago, not really knowing much about the technology sector. For those of your listeners who may not know much about Verily, let me give you a little bit of background. Verily originally started as a part of Google X. We were originally called Google Life Sciences, and then we were spun out and became one of the best of the Alphabet family when Google became Alphabet. From the beginning, we were purpose-built to develop life sciences and healthcare products. When I joined about two and a half years ago, I was to lead health platforms. Our mission really has been to think about how we can leverage some of the really remarkable capabilities in Verily, whether it’s new sensors and devices like continuous glucose monitors for people with diabetes or big data analytics, machine learning capabilities. And how do we leverage all of those in order to really improve our healthcare system and help reduce the cost of care. We are very mission driven organization and we’ve been very fortunate to attract some really wonderful talent. I feel very, very privileged to be in this role.

PP: [00:03:03] Thank you. That’s a great background. Vivian, you’ve had a very distinguished career, you’ve been a healthcare leader for a long time, you’re a clinician by background, and you’ve spent a long time with some leading providers across the country and now for the last couple of years you have been on a technology firm. What is the change been like? Can you maybe touch on a couple of your observations or learnings from your experience in the last couple of years at Verily?

VL: [00:03:38] Yeah, I’ve learned so much and thanks for this question, because it’s really interesting for me to reflect on just how much I have learned. There is so much complementarity between the healthcare environment and the technology environment and culture. I feel like the intersection of the two is exactly where there’s a sort of a sweet spot in terms of what I think we need in the industry in order to improve health outcomes and reduce the cost of care. And I’ll give you a couple of examples. When I went through medical school and residency and training and then worked in a number of different healthcare environments, I was always taught that we as physicians are really providing healthcare to patients. It was sort of more or less a unilateral kind of relationship. We understood about biology and physiology, and we had medications and tests that we could perform or operations that we could do. It was really our job to deliver health to people. When I joined the technology side, I came to realize that there’s a very different way of thinking about the relationship between the provider or the business and the customer or the patient. It is really the one that is much more about co-producing, co-designing, and really working together. And that plays out in the way in which we think about, for example, digital health, digital technologies or virtual care. So, when we have our company called Onduo, which is a digital health company, really help people with chronic diseases like diabetes, cardiovascular disease, like hypertension or mental wellbeing. We actually don’t think about ourselves as being the provider of health. We think about how do we work with people to co-produce their own health. We can provide information, for example, from a continuous glucose monitor about their blood sugars. We can help them take pictures of their meals and snacks from their camera on the app on their cell phone. And then they actually make the visual association between what they’re eating and how they’re sleeping, how they’re exercising, and then what their blood sugars are doing. We might make some recommendations using our algorithms and say, Paddy, for you soya milk seems to be better than skim milk in your coffee. But Vivian, for you maybe the skim milk is better. That can be helpful, are we’re really helping the individual produce their health. So that’s one example of how the intersection between traditional healthcare and technology can be really beneficial to improve health outcomes.

Another example is, in healthcare we have traditionally kind of used a one size fits all approach to caring for people. When I was in medical school, every patient was a 70 kilogram white male. The medications were dosed as if the individual was a 70-kilogram white male. And someone just corrected me yesterday and said, on these days, it’s like the 90-kilogram white male, which is not a good direction to be going with. On the technology side, of course, we all carry around very similar phones, but our interaction with those phones, the way we use the phones, the experience we have, and the benefit that we derive from them is extremely personalized. That’s another example of where I think technology can help us in healthcare. Think about how do we create healthcare solutions that are really personalized and sensitive to cultural differences, the language differences to differences in perceptions about our own health. And making it engaging so that people can again, co-produce and co-design their own health.

PP: [00:07:43] Those are great examples of the intersection of healthcare and technology. Now, the third element of that, which I know Google is really strong at, is the data side of it. Google is known for its ability to aggregate very large data sets, make sense of them, apply advanced analytics algorithms to them and identify insights that can drive action. And I can’t think of a sector which can benefit from this kind of capability more than healthcare as we know it today. So, my understanding is that Verily is focused more on the clinical research side of it, although you did mention the partnerships with Onduo and I’m aware of the partnership with Dexcom. And more recently Fitbit is going to be part of the family as well. Can you talk a little bit about how the data element plays into your overall mission for driving improved healthcare outcomes?

VL: [00:08:52] Verily is actually a sister company to Google, we are both part of the Alphabet family. Of course, Google is a much bigger sister than we are, but we’re actually a completely separate company in many regards. So just to clarify that, we all are definitely part of the Alphabet family, though. Your question about data is a really good one. Our roots are in research and in clinical research, that’s definitely how Verily got started. So, that’s why when I joined about two and a half years ago, getting close to three years now, actually, my charge was to think about the delivery side of healthcare. And your question about data element is really a spot on. So, we think about it in terms of are there new data sources we should be introducing that can actually help engage people and drive better outcomes? One example of that is our work in the continuous glucose monitor technology, which we have done in partnership with Dexcom. So, there it’s really a matter of saying that people with diabetes in the past, the information that they had about their own blood sugars was really based on either of these hemoglobin A1c blood tests that you might take every six months or even a year. Or maybe if you’re daily doing the finger pricks to check your blood sugars and saying, well, maybe that’s not enough information for individuals to really manage their blood sugars successfully. And so, the idea of having a continuous glucose monitor, is maybe the size of a key fob that you might put on your arm or your abdomen. They can measure your blood sugars 24/7 for a couple of weeks. At a time, it can provide whole new levels of insights for individuals and whole new data sources for people in order to manage their health better. And so, that’s one example of data, thinking about data to provide not only insights, but personalized insights, because my blood sugar reaction to what I eat is going to be very different from yours. We see that consistently across thousands of people that are part of our programs, that we all are very different. Our physiology is very different, our microbe biome is actually very different. And that is the way our blood sugars react to our meals and exercise is actually very different. Another example of data is in a different area that we’ve been working. We actually started a new company, which is a stop-loss health insurance company. We announced that last year in partnership with Swiss Re and there we have a whole different kind of approach to data and analytics to create what we call a precision risk analysis. So, this is for employers who are self-insured and are, of course, managing the health of their employees and covering the insurance. And enabling them to have a more precise understanding of the risk of their employee population. The purpose is to enable us working with them and to think about how they can reduce the risk if they can see some of their populations of patients are at higher risk. For example, developing kidney problems or developing cardiovascular problems, how can we intervene and lower that risk? So that’s, again, very data driven, data science, and analytics driven. So those are a couple of examples.

PP: [00:12:53] I will come back to the point you made about helping employers manage their employee population and manage their health, especially for chronic conditions such as diabetes. But thank you for clarifying the organizational structure. Many of us, me included, may not have been entirely familiar with how Alphabet and Google and different companies within Google are organized. So, thank you for clarifying that. I am aware that it is really a separate company and you have investors besides Alphabet as well. Let me switch to the topic you just mentioned, the employers and their desire to control the costs of healthcare for their employees. And everybody knows that one of the biggest components of any employer cost base is healthcare and is certainly one of the fastest growing in terms of the inflation year upon years. And in your book, The Long Fix, you addressed and you talk about why we should be concerned not just about the cost, but also about what we’re spending on. Can you elaborate on that a little bit for the benefit of our listeners? What led you write the book and what was the central theme or message that you were trying to communicate through the book?

VL: [00:14:31] I wrote the book – The Long Fix – during a sabbatical after serving as the CEO of a healthcare system for about six years and the dean of the medical school actually. And the audience for The Long Fix was really the general public, people who wanted to understand why is it that our healthcare system seems so dysfunctional? Why is it in the news all the time? And why there is fundamental paradox of healthcare in the U.S. that is we spend so much money on healthcare in this country. We spend about two to three times as much per person on healthcare than any other high income country in the world. Yet when you look at our health outcomes, we’re really at the bottom of that list of those high-income nations for the most part. And so how we are overspending and yet underperforming? And one statistic, for example, when people say, I can’t believe our health outcomes are really that much worse than Germany or Australia. And actually if you look at longevity, that’s one of the measurements. I mean, how long on average are the babies born today going to live right now? The current projections are for five or six years, not months, but years, less than the average baby born in Italy, Japan, Israel, and Australia. It’s really stunning. And so, I really wanted to understand this question and I wanted to offer some thoughts about how we could actually get to a much better place. And those thoughts were not my own thoughts, or they were just a figment of my imagination. They were really a lesson from across the country where there are fantastic examples of much better performing health systems, much better ways of thinking about improving health and I wanted to share those success. And so, that really was my overarching goal in that book. And one of the targets was employers. So, I have a chapter just dedicated to employers with this. I think there is a 10-point action plan at the end. Employers, as you know, cover healthcare for half of all Americans. So, they are very important group of individuals who really need to understand how to bend the cost curve for their employees and keep them healthier. Also, it is important to understand that they’re financially and operationally motivated to do that. And yet they really haven’t had the tools. And so, I wanted to lay out and I wanted to provide in that chapter some really fantastic examples of how employers have worked together with healthcare systems. They worked not only to get better health outcomes for their employees, but actually lower their costs of care and get those costs down. From interviewing people and from talking to people, I put together basically an action plan. So those are some of my motivations and some of the areas that I talk about in the book.

PP: [00:17:56] There have been several examples of employers finding success, with addressing maybe, specific conditions such as diabetes, for instance, and partnering with companies such as the ones that you’re associated with. This is also a good time for us to talk about at least one experiment that didn’t turn out as expected and I’m talking about Haven. What are your thoughts on that? Because the whole model was essentially what you just described, which is to take control of the costs and try to influence it as employers by looking at it holistically. And also, trying to find ways to bend the cost curve and to improve the outcomes. I’m just curious to know your thoughts on that. What we may have learned from that?

VL: [00:18:53] I think that we’re starting to see analysis of that, and I’m sure there will be many case studies written across business schools all over the country about lessons learned there. When I was really studying this space from the perspective of having been an employer. And when I was at the University of Utah, we had about fifteen thousand employees plus their dependents. We actually had a health plan, initially that was just for our own employees and for some Medicaid members that we were responsible for. And then we took a commercial license and became a commercial health plan. Because so many of the employers in our community were really interested in how we had been able to reduce the cost of care. And then interviewing around the country, I thought people became very clear that as employers, we actually really have levers for driving change in this country that we’re just not tapping into.

One of the stories that I talk about in The Long Fix, is about what happened in Seattle at Virginia Mason Medical Center. One day, the chairman of medicine was informed that four of the big employers in Seattle who had been sending their employees to Virginia Mason Medical Center for their care said that we’re going to stop doing it. This is because they were too expensive. And those employers were people that we all know about, like Starbucks, Costco, Nordstrom, for example. And when he sat down and started looking at this, he realized that these employers were the ones who are actually paying his salary and his team’s salary. They were actually his payers. And secondly, he realized that the relationship between them and the employers really need to change. And the employers realized that healthcare was like a supply chain issue for them, if they couldn’t get good healthcare from Virginia Mason, their employees couldn’t work. It was just like if you couldn’t get a chip into the Intel factory, your business would just stop if their employees couldn’t work. So, they started declaring specific performance specifications specs just like they would for any other supplier. They would expect that Virginia Mason would deliver on those.

Once they started to have that kind of a conversation and they actually got more engaged in helping Virginia Mason perform better. It actually completely transformed the way in which Virginia Mason practiced to actually become a much better health system. And that’s why they became a center of excellence in Walmart and Lowe’s and G.E. started flying their employees all the way over there just to get care. So, I think there are lot of lessons from those experiences that still make me feel very optimistic that employers have a really big role to play in transforming our healthcare system.

PP: [00:22:10] That’s a great example, and I’m sure that this whole space is going to be carefully analyzed and I definitely see a trend towards employers taking more and more control over their costs. I wanted to go back to this idea of one concept that you mentioned in one of your earlier comments and for the benefit of our listeners. You mentioned the stop-loss insurance company that you’ve started in partnership with Swiss Re. Could you just explain briefly for our listeners, what a stop-loss insurance mean?

VL: [00:22:48] About half of all Americans receive their healthcare through their employers. And if they’re large enough, they can decide that instead of doing this through an insurance company, they can in fact be the insurance company. They can take the financial risk an insurance company would take because they’re big enough. And so, they just set aside a pool of money every year to pay for the healthcare costs of their employees. And then usually they engage in insurance company to be the administrator, to send the bills, to pay the hospitals to deal with prescriptions and so on, so forth. When they do that, they’re usually referred to as being self-insured. And when they are self-insured employer, they still may want to have some insurance just in case there are exceptional things that happen. For example, say an employee has a diagnosis that requires a very expensive treatment or gets into a really bad accident, heaven forbid. That’s called stop-loss insurance. Also, they’ll take out an insurance plan just to cover really high costs of care for individual employees. Typically, when we do that as an employer or if we buy stop-loss insurance, it’s usually just a set cutoff. So, we’ll say, we just want to insure against any claim that’s over, say, one hundred and fifty thousand dollars of anything above that. The insurance company will cover it. And it’s kind of a one size fits all. And what we’ve been doing is really thinking about it in a more precise way, saying, well, you know, some people in your population may be at higher risk for having a really expensive condition. For example, they might look like they need a transplant in the next year or two. Whereas others statisticians and the actuaries would tell us is a very low risk. And so, we’re starting to basically look at this space and refine it and make it a lot more precise. That enables us to identify those people who are at high risk. So that we could potentially lower that risk and maybe provide them a transplant if we can actually intervene early enough. Now, that’s really our goal.

PP: [00:25:19] Another great example of applying data and advanced analytics to try and influence the costs. Switching back to digital health and technology. One thing that I find is that healthcare traditionally is better than anyone else. It is cautious and slow for very good reason or patient safety and a host of other issues. Technology, on the other hand, and especially, Silicon Valley based technology firms, they move very fast, they break things and fail fast. These are the kind of buzzwords that drive the way they do business. How do you reconcile these two instincts in your role and given your background when you’re trying to really accelerate the pace of change, but at the same time do it in a risky containment manner?

VL: [00:26:20] That’s a really interesting question. And in fact, we’ve seen it in the last nine months in response to COVID. Back in March, when it was really clear that we needed a lot more lab testing. And if you remember when all of us started to get shelter at home and there was such a shortage of testing and we just could see the numbers taking off. But we just didn’t have enough information about what was going in the country because we didn’t have enough testing. Our company was drawn into that. And Verily began to build these community-based COVID testing centers starting in California and then all over the country, often in partnership, for example, with Rite Aid. We actually turned over almost overnight into a company that had full of these data scientists and we have laboratory scientists, some clinicians. And all of a sudden we were becoming PPE experts and printing out bar codes for lab testing, it is really remarkable.

And the pace of that change, Paddy, was just fantastic. Our team in the health platform side were reached out by a number of employers. Because obviously we work with so many different businesses and said – “how can you help us now during COVID?” So, very quickly we were able to stand up a whole new business. It’s called Healthy at Work. It helps employers keep their employees safely in the workplace or bring them back to work safely. It includes everything from the app that it helps to check their symptoms, helps them order their lab tests. We’ll send people to do the testing or you can do it yourself. We have kits and hundreds of thousands of employees that built this entire business and now, using our program.

And it was done in such a record speed. I find it really remarkable. Our engineers work 24/7 to write the code, our quality people, our FDA approval regulatory team just work non-stop. That pace, I think we saw a lot across the whole country, the private sector really stepping up. Look at how quickly vaccines have been developed. At the same time, I think what you’re asking is sort of the balance, the yin and yang of that. And I think that it is really important that in companies like Verily, we do have seasoned healthcare executives. And so, I feel very fortunate to be a part of a Verily. My Chief Clinical Officer is a long-time physician, Vindell Washington. He was the National Coordinator for Health IT under President Obama. We were very fortunate to work with Robert Califf, who was the former FDA Commissioner under President Obama, who now works with us and with Google Health. I think we also have that element of a deep understanding of healthcare and recognizing that healthcare is different from many other industries. It’s really vital for us as a health technology company to protect the people that we care for and to maintain that trust. And then we need to earn that trust. And that’s something we all learned in healthcare as clinicians and people caring for people and making very important decisions with them. But it’s especially important in the technology sector, especially these days, we have to balance each other. The speed is absolutely essential, but the care that we take and that maintenance of trust is absolutely vital as well.

PP: [00:30:37] That’s so well said. I can certainly appreciate when the challenge is thrown at us, how we can turn around and do things that we didn’t think we could do. So, I heard someone made a comment the other day, and apparently this taught us that we’re limited not by what we can do, but what we think we can do. So, to your point, coming up with a vaccine in nine months I don’t think this would have been possible a couple of years back. It’s similar to the alacrity with which we’ve turned it on and responded to the crises in PPE production and the testing. And all of these are fantastic stories that we can learn from. If you look deeper and find out how as a community we all got together and really overcame this challenge.

I want to touch upon the outlook for digital health startups now. Digital health startups have been raising a lot of money and many of them have gone IPO. All of that continues to look very strong. The outlook seems very strong. Is this directly a function of health systems transforming themselves and really picking up the pace of change? Or is this more of a longer-term outlook with the sort of thinking that this is going to happen sooner or later? So, we’re going to make our next now and wait for it to happen. Is it already happening and what is driving this activity? Or all this activity is in anticipation of something that we all expect is going to happen?

VL: [00:32:35] Well, COVID is definitely accelerating everything. It’s almost unprecedented to have hospitals and clinics essentially shuttered except for their COVID wings for such a period of time. And for people who are most vulnerable, also being the ones that really need that care, people who have chronic conditions. The folks and people in nursing homes, the frail and elderly who actually need access to healthcare are the ones that are most afraid. This is because they are most susceptible to COVID. So, in that kind of environment, it became obvious to everyone. Obviously, you can see from the telehealth numbers that overnight every healthcare system developed a telehealth offering. And then, we recognized that in telehealth, while it’s very helpful to be able to text or video conference with a clinician, that doesn’t supplant in-person visits there. You need to make measurements, or you may need to listen to somebody’s heart and lungs. There are a lot of things that you need to do when you have an in-person visit. So, again, there’s more interest in expanding beyond telehealth to other digital health offerings. And I think everyone could see even before COVID that this is a direction that was really exciting. As we have gone with continuous glucose monitors and people with diabetes, the new sensors, the new attachments can go on to different phones. It’s been a really interesting area, a very innovative area. A lot of things coming out. I think most of us think that it’s relatively early. I think what will be developed in digital health is just going to be pretty phenomenal over the next few years. I can’t wait. I’m actually really excited to see what happens. And so, I think this is an enormous excitement and some of the barriers to digital health in terms of reimbursement and some of the regulatory issues also fell down overnight with COVID. Now, it’s not clear that those are going to stay down forever. But I think that also freed up the market probably a little bit more. One thing that’s important that I do want to mention, Paddy. It’s very important that innovators in digital health think just as hard about innovating in terms of the way in which they’re paid as they do about the products. And I’ll give you an example of that in our own work. So, in Onduo our disease management platform in healthcare is a very much fee-for-service model right now. That is one of the themes in my book, The Long Fix. We need to move from this model of paying for people to do things to us in a fee-for-service mode like more procedures, more operations, more imaging studies and so on. And instead, I think are we really getting better health or are we actually getting healthier with all this treatment? I think the same thing is true on the digital side. That is instead of recapitulating some of those weaknesses of our current healthcare system, say – “pay me every time I click or text or for video conference.” Instead we should get paid for showing that we’re actually improving health outcomes. And that’s what we’ve done actually in Onduo. We’ve had a few several contracts with payers. And we only want to get paid if we are actually showing people with diabetes have better blood sugar control, people with high blood pressure have lower blood pressure. People who need their eyes checked, get their kidneys check because they have diabetes, have had those things done. And kind of putting our money where our mouth is in terms of really moving from fee-for-service to a more value-based model. So, I’d like to see digital not only transform care, but also transform the way in which we pay for care, the business model of healthcare, because I think that’s really where there’s a huge opportunity.

PP: [00:36:56] I couldn’t agree more with you in that. That really is the opportunity ahead of us. I have just one last question at a personal level. What are you currently reading?

VL: [00:37:11] I just finished the book Team of Rivals, which is the book about Abraham Lincoln. And that was partly motivated by what happened in the summer, in the fall Black Lives matters and just really wanted to think back. About that, I am actually reading something called Seven Brief Lessons on Physics, my daughter suggested this by Carlo Rovelli. I’m reading that on my phone. It’s beautiful little vignettes about physics. And I’m also reading Bill Bryson’s, who’s one of my favorite writers, just to distract myself – Made in America.

PP: [00:38:07] Fantastic. It’s such a coincidence that I am reading a book titled Forged in Crisis. It profiles six different leaders and Abraham Lincoln is one of them. And I’m actually in the middle of that chapter right now. There is something common there. Vivian it’s such a pleasure speaking with you and having you on the podcast. And I look forward to following all of your work at Verily and all your other initiatives. Thank you once again for being on the podcast.

VL: [00:39:14] Thank you so much, Paddy. Really enjoyed it.

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Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity