Confronting the Obesity and Diabetes Epidemics

Confronting the Obesity and Diabetes Epidemics



welcome to the session on diabetes and obesity the the two major pandemics that I think we face in the United States and I'm calling them pandemics because it's a global issue I think we have a fabulous panel today beginning on my left with Oh actually I don't have your name down it's a joke I think you gotta remember I know exactly risk who's CEO sorry next is Mark Hyman who's the medical director of the Center for functional medicine at the Cleveland Clinic to my right is Kelly close who's the founder and chair of the diatribe foundation and president of closed concerns and next to her is Sean Duffy who is CEO and co-founder of Amada health and finally Hugh wall waters director of health economics research Milken Institute and Hugh we're going to start with you to see some data great thank you yeah so I have the pleasure of giving all the bad news at the very beginning and then the rest of the panel will then give you the solutions to these problems so I'm in a bit of a very quick overview of some of the economic impacts of for starting with the chronic disease burden in the US and then looking specifically at obesity and diabetes in terms of the epidemiologic and economic outcomes associated with those two so I'll go ahead and bring up a slide see okay first slide so we've done at the Milken Institute a very detailed study on the cost of chronic diseases in the US using a wide sore you know a wide variety of sources of data from Center for Disease Control from American Heart Association from a number of other professional organizations but very using very detailed and reputable sources on both prevalence of these diseases and also the costs of these diseases so categorizing chronic diseases broadly and into these categories we calculated that the direct cost and when we say as health economists we say direct cost we mean that costs actually a healthcare delivery what patients pay what insurance pays ends and what employers pay for the health care itself so that's what we call direct and as you can see if we group chronic diseases into large categories the total is 1.1 trillion about 5.8 percent of our of our GDP s and you may know that health care spending in this country is a little bit over almost 19 percent so so a significant portion of the US healthcare spending in this country goes directly to pay for treatment of chronic disease if we go to the next slide if we combine the direct health care costs that treat the treatment of the diseases in the healthcare system if we combine that with productivity losses what a health economist called indirect costs so these include lost productivity lost work time the the effects of the chronic diseases in terms of the economic total economic outcomes we can see that the costs are much higher so some of these chronic diseases lead to a lot of obviously disability of reduced productivity in the workplace so the total costs calculating using indirect and direct cost together are almost 20 percent of our economy nineteen point six percent of GDP three point four trillion dollars and you can see looking at the the categories you can see that you know diabetes is a significant chunk well over almost half a trillion dollars over five hundred billion dollars cardiovascular conditions in general all by themselves more than one trillion dollars in the u.s. so we're gonna be talking today about obesity and diabetes which really underline a lot of these things which I'll just get to here in a second okay I'm like okay here we care sorry about this cost of diabetes if we look at it as a subsection of these costs total treatment costs direct health care in terms of again hospital hospital visits healthcare visits about a hundred and ninety billion in the US and including the productivity cost this is the difference between the direct health care treatment and the indirect productivity losses if we include the indirect productivity losses almost half a trillion can can be attributed to diabetes the diabetes epidemic and you the US so so it's a significant significant chunk of change okay and then of course obesity and being overweight this is the study that we have done it's a very again very detailed looking at each of the specific diseases the spending on those diseases and then looking at the portion of the spending that can be considered attributable to to obesity so the way we do that is it's a mix of Epidemiology and economics to really calculate correctly the the attributable risk yeah in the epidemiologic sense that's due to obesity you need to know two things you need to know the prevalence of obesity and you need to know the relative risk relative risk is how much more likely is the person who has obesity to get that condition whether it's diabetes or cardiovascular disease then a person who does not have that condition sorry keeping everything else equal level how much more likely is the person who has obesity to to have the healthcare condition in question so that's that's a relative risk and so the relative risks are kind of stunning so it makes you think a little bit about your diet perhaps so if you have obesity in the u.s. you are three point four times more likely to have diabetes holding everything else constant if you have obesity you're over two times more likely to get Alzheimer's disease or vascular dementia so if you if you take those number and then congestive heart failure 1.3 times more likely coronary heart disease one point six times more likely if you take those numbers trying to go backwards okay if we take those numbers and go back here okay so you can see so these conditions alright so obesity twice as likely to have Alzheimer's and vascular dementia if you have obesity so in other words a significant contributor to the light-blue PI diabetes three point four times more likely to have if you have obesity the big blue slice of the pie and cardiovascular conditions varies depending on the condition but also significantly more likely if you have obesity compared to having a healthy weight that's that's the concept of relative risk so so using the relative risk and using the prevalence of obesity we can calculate in gory detail which which is the total contribution of obesity so so the total cost of diseases due to obesity is an update of a report we did a couple years ago now it's updated with the most recent data so first of all almost 40% of US adults have obesity using data from the Centers for Disease Control total costs 419 indirect healthcare costs for 219 billion one point one five trillion in the indirect costs lost productivity lost work time total one point five seven trillion dollars a lot of zeros on that eight point five percent of u.s. GDP and forty-seven percent of the cost of chronic diseases so if we're interested there's other contributors to the chronic disease burden smoking alcohol abuse when we've actually teased out the relative contributions of those as well but a obesity and overweight are by far by far the single biggest contributor to the chronic disease burden so I guess that's maybe a good way to turn it over to the rest of the panel yeah in my eagerness to get into this panel I forgot to introduce myself I'm Bill Dietz I'm the chair of the Sumner M redstone global center for prevention and wellness at George Washington University and prior to coming here I was the director of the division of nutrition physical activity and obesity at the Centers for Disease Control and Prevention so I wanted to start with a human dimension on the costs which Hugh outlined because I think that although the costs are important the human side is equally so they're there thirty million adults affected by diabetes and additional 84 million are pre-diabetic 93 million adults have obesity and it's a major risk factor for for diabetes and prediabetes so these data raise several critical questions how do we care for those affected with diabetes and how do we prevent progression to diabetes of those with pre-diabetes and obesity one of the things which you didn't mention is that these diseases obesity and diabetes particularly affect underserved populations there's a higher prevalence among mexican-americans and among African Americans and there is an increased prevalence among those in poverty so the first question for this panel and that I want to pose and will hate comments on it are the demands referrals incapacity all appear to be barriers to treatment for diabetes and obesity so how do we overcome them and starting with Kelly I think a an important piece of this is communication and do PR people aware of this and and how what kind of steps that they can take to either prevent or treat their diabetes yeah thank you thank you so much and and for having this panel what an honor to be here with so many of you and so I work with a lot of patients we send diatribes org out at the newsletter that goes out about every week to about 200,000 people and people always say to me that's growing a lot you know since five thousand five years ago and it's like actually I mean it ideally would be going out to many many more I think if people have diabetes they don't necessarily want to sit around and read about it and if they're at risk of it as you say you know they are probably at lower socioeconomic levels they are struggling maybe they have three jobs maybe they have you know many other things in their lives and they don't necessarily know that it's addressable right so I think as a society it's it's not just really even thirty million or eighty four million people it's three hundred and thirty million people in the US alone who we would love to have working toward health citizenship you know I think that there are a lot of a lot of different things that could happen if the awareness was more at the educational level and really a multi-stakeholder approach a lot of what we see here at the at the Milken Conference but I I think it's just very important to have cultural shifts we heard you know and maybe we could just pull up slide eight we could just look at this really just really quickly some of these factors are not modifiable but some of them are modifiable and this is from Allen Moses former former chief global medical officer at novo nordisk but many of these things could be addressed and I couldn't talk about that more as we go on but I think people with diabetes feeling that they have a menu of options it needs to be fuller it needs to be more directed and it really really need to feel as patients that we're being invested in it's not a cost great mark you've really been in the trenches of treatment I did a back of the envelope calculation awhile ago suggesting that for every primary care provider in the United States there are 90 patients with severe obesity BMI greater than or equal to 40 so how do we how do you build that capacity and and the work that you're doing and how do you how would you suggest we expand that so in terms of training and meeting these what I think the problem is we're focused on the wrong end of the stick in treating diabetes because it's it's something that we're you know focused on treating with medications or medical care in hospitals and clinics and the problem isn't there the problem is upstream which is our food system and the social environments in which people live and the poverty and so forth and and those have to be addressed and if you don't address that you're not gonna be able to solve this epidemic it's not more and better medication which everybody is seeking and one endocrinologist the Cleveland Clinic told me that their insulin went up like 300% recently some of the some of the doses they use or things and I think that we have to really focus on creating system solutions to the problem that involves asking really two questions you know what are the drivers that we can modify what is the biology of the disease in the cause and it's predominantly you know food and particularly carbohydrates I was a paper published in cell last week called car about carbo toxicity and its effect on an insulin resistance and the progression of diabetes and I think that the second thing is is how do people change their behavior and environment I think that has to be done through more a social solution what I call social cure it isn't in the hospital it's democratized to centralized care that's in the community and I've been involved a number of efforts to test that one is with rick warren at Saddleback Church where we created something called the Daniel plan which is a faith-based wellness program would the the operating system being functional medicine and died this low glycemic anti-inflammatory high in fiber good lots of good fats and doing it in peer supported groups that allowed people to get the support accountability feedback that they needed to change behavior and we had we thought a few people would sign up at fifteen thousand people signed up the first day was the biggest event they ever had they determinate 2,000 people we ended up having the group lost quarter million pounds in the first year but also all the disease's went away as a side effect of creating health so we focused on treating disease we should be focused on creating health and doing it in communities that matter we now have launched that in 28 churches in Cleveland and poor communities that's very successful so I think we need to sort of rethink the delivery model and also the the type of care we're doing we had a patient in one of our shared medical appointments which is sort of a secular you know Daniel plan group model and and we do these groups called functioning for life and one of us on diabetes and we had a patient recently who had a hemoglobin a1c of 11 which for those of you know the medical field is extremely high poorly controlled diabetes her she had heart failure should kidney failure she had none of dialysis but renal insufficiency should fatty liver hypertensive on a pile of meds and three days she was off insulin in three months her heart failure reversed her kidney failure reversed her liver problems reversed she was off all her medications and her a1c was five point four and she lost 43 pounds and it was a side effect of just lifestyle education it was a 20-hour two hours a week program for ten weeks supported by coach nutritionist so we don't know those things don't really easily get reimbursed in the system and we're looking at bringing those into the community and we're looking at for example other solutions like food pharmacy solutions we're trying to launch that at Cleveland Clinic based on Geisinger model other people doing it but when you look at the date on that was striking these were food insecure patients who had poorly controlled diabetes where they once he's over ate they I think they had a hundred a couple hundred patients in it they provided support coach nutritionists education to some cook shop you know basic things in the community and the average cost went from two hundred forty thousand per patient per year to a forty-eight thousand which is $192,000 saving per person or eighty percent cost reduction and all the biomarkers got better and their quality of life improved those are the kinds of solutions when you'd be thinking of that are more democratized to centralize that are outside the box that are not on the walls of clinic and putting people and communities of the center of health care not doctors and hospitals because we're not going to solve this in the clinic so thank you and we're fortunate to have two technology solutions on this panel and Josh I'd like to start with you and how how do physicians or other referral groups know about the kind of work you do and our referrals the problem is the demand there do you and what can you say about the growth yeah I ask you the same question sure so I know I'll back up to being your bigger the question you asked is how do we prevent this epidemic or pandemic and we I completely agree communities important where we get our food from what we teach in the school critical and and I used to run a smoking cessation program for optim and we were really successful because everybody in every state is eligible for some degree of smoke cessation program and so when we could do the same thing with pre-diabetes obesity and diabetes I think we have a chance so me as running a company called on duo I may get a a contract with an insurance company or maybe even two insurance companies so then when I try to do a population or public health campaign I'm trying to find the people that have anthem insurance in a given state as opposed to what I could do when I was at optin because we had quit for life the smoke cessation program I can say to everyone call me because I'll have a program that you could get paid for your smoking cessation so until we have public health campaigns I think it's gonna be really hard that said what we do it on do I'm Canadian and I used to love Wayne Gretzky and we go with the concept of go where the puck is so you don't like him anymore try laughing so so he moves away this idea of hey you know prediabetes amazing great love it right OBC great love it but guess what there's still 30 million people who have diabetes right now and that's where the puck is and I think that's where we can make a difference and you you you said something that there's 90 people for every primary care doctor who have obesity but every primary care doctor might have a panel of five hundred thousand 1500 patients so when they think about when am I gonna learn today am I gonna invest money what am I going to invest resources it's not obesity and it's certainly not diabetes and so what we're trying to do it on do oh just by creating these virtual clinics is can we democratize what we consider Centers of Excellence so if you actually go see an endocrinologist for diabetes except for an eye and foot exam there's no there's not a lot of physical exam there's not a lot of physical interaction so the idea is can we bring that specialty care in terms of remote monitoring continuous glucose monitoring expert nutrition advice expert medical advice and even endocrinologist through telemedicine can we bring that into the primary care doc so everybody not just wealthy people who could get access to joslin diabetes or Cleveland Clinic can then get the best care and and we were talking a little bit earlier about this is we talked a lot about access and I show this great graph of where our members are and where the endocrinologists are but what we discovered is we know social economic status and access is really important because if you're working two jobs you could literally live next to the Cleveland Clinic you're not going to take the time to go see endocrinologist so how do we make it really easy and I think that's where Sean and I have this you know great medium which is your phone I mean we could do a lot of things digitally so we can potentially get to 30 million people and not just great well group right so that's the treatment side the prevention side yeah so your question was in two categories on demand and referrals and both unfortunately don't have shortcuts I think the UM really quickly so Omata at a high level think of us as an online program that helps people with obesity related chronic diseases we got our start in early risk so pre-diabetes and have expanded you know from there so what's interesting on demand per Josh's comment it's so important to meet people where they are which in today's world is in front of their screens and that's especially true in chronic disease and I think if you could draw a graph of digital relevance and a cure disease chronic chronic diseases are more relevant to digital worlds because you have to intervene on a multiple multiple times for a long period of time so anything chronic needs to be addressed through digital and that's for a whole host of reasons and the critical one is of course outcomes because in order to get outcomes you have to touch people many many times longitudinally and that's great for digital and that actually helps with the demand side because if you make it easier to live with a chronic disease by making exceptional product experiences that are on your phone by preventing a visit where you have to schedule time off of work to drive in to get a refill on a med I couldn't that matter I couldn't have that happened in a different way if you make it simple and elegant that actually increases your bill to have impact because it pulls on demand and through tech you can market in really interesting ways so you know what I always say when we communicate the value of a modest program is our goal as you know and from a marketing design team is to put out something that people feel surprised that it's covered for them and and they're like well that's interesting because this looks and feels like this sort of thing that I would have had to pay for and that can be done in the chronic disease spectrum so that's on the demand side on the on the referral side it's it's reimbursement and I don't you know there are ways to get enrollments into the program we partner with IT ends like Kaiser Permanente we work with many many plans and employers and figure out all right well where are the contained populations where we know that if we mark it inside it we can get people in and get them paid for and increasingly our company and others in our space are getting just in network full contracts where we're reimbursed where it doesn't really matter where the person comes from a clinician could recommend it as the reality is if you take a PCP and you approach them and say hey look here's what you're doing today for your pre-diabetics here maybe handing them a pamphlet saying lose weight you're maybe referring to a dietitian and nutritionist and then you stop there we have an amazing program it's evidence-based here's our 12 trials here's it's gonna be elegant your patients are gonna love it if you come in with that message what you're gonna get back is which payers are you covered for is their access and unless you have a critical tipping point of payer coverage for that doc in their panel it's not gonna happen you will not be able to influence or move that practice to be able to refer so you have to get to that point and you get to that point by skating where you do have coverage just getting those critical tipping point coverages and that can kind of catalyze the rest and this is on a journey we're all on a journey together here I think we will get there I am more optimistic this year than ever before that five years out it will be possible for PCPs to refer into programs like LaMotta and on duo it's just a long road and it's gonna require continued resilience and determination right so one of one of the concerns about about all of these programs is the is the extent to which they're able to address the ethnic and socio-economic disparities huge you began to touch on this mark but you know we're not going to have health equity unless those disparities are eliminated so again I mean your your communication strategies are probably reaching an Elite my guess is so how do you how do you broaden that to reach these hard-to-reach populations who are disproportionately affected yeah you know I mean I think we need to do a much better job of having conversations and being in community you know and it's time-consuming I mean I love hearing about the faith-based strategy that you're you were talking about in Cleveland this is so compelling there are really interesting they're really interesting initiatives like this in Houston also like dr. faith Forman is doing this with these changing diabetes I sometimes feel like and I visited Geisinger is amazing Shamokin Pennsylvania they're 23% of that town has type 2 diabetes you know I mean then the percentage of people who are under the poverty level and like you you go there and it's time-consuming and I feel like it's really passion you know it's sort of fashionable to talk about partnerships and to talk about multi-stakeholder efforts like the amount of time and effort and commitment and investment that we need to do I mean like listen to what Esther Dyson is doing like go to her communities and guess what it's like they're not all nonstop flights from JFK or from SFO and all of that and you know as a culture we need to be much more committed and also looking globally at what is where where these things happening I'm the diatribe foundation worked last year to call hundred people all over the all over the country didn't get as many global examples as we had liked but had a lot of conversations with people and said you know Jim Gavin said to us find out like what is working what's working what's not working Phil Gilbert runs design in IBM he was at this gathering with Esther and Sean and I you know a couple years ago IBM had no idea what was working and not working and we went and found out this information and put it in you can see it all it's free diatribe dot org slash anthology we have little summaries on the way out but like what is appealing to these multi stakeholder groups is really a big deal to figure out you know like patient centered all of that it's fashionable like we're in the room but have you actually invested in patients across the whole spectrum and have you actually figured out what are the different things that that so that so many different sets of patients and their families and their employers need because you might not you know as as joe says I mean the number one thing might not be thinking about how to prevent diabetes if you are worried about how you're gonna get dinner and this is going to go into a whole host of questions about policy like we live in a country we subsidize corn in this country that is crazy when we look at what is healthy food no one even agrees so I'm excited about the opportunities and where it's going but I think it does need to it does need to move beyond you know where it is right now and have have Cleveland Clinic Milken Institute have Big Pharma all working together well we'll come back open so Shawn you you said that your current contracts are with groups like Kaiser Permanente but can you to what extent are you enrolling Medicaid or Medicare populations and are the outcomes in those groups the same or different and if they're different which I suspect they are how do you elevate the the success in those yeah it's so it's a great question we work with a number a number of commercial payers in the private side we have eleven Medicaid contracts you know the there's the CDC effort to put forward these Medicaid demonstrations and we're the digital fighter and thinking like seven and nine of them and and what I always would always say when I start with not just not just Medicaid but even seniors too is you you have to answer the question and sometimes it's asked like ten seniors use technology with the response that's how do you build technology that seniors can use because there are many many UX details integration details like all the little things really matter and it matters and underserved and matters and seniors so the first is can people use it like we deliberately put a cell chip in a scale versus having people pair it with their Wi-Fi or home network or Bluetooth phone because my mom can't pair a Wi-Fi scale with our network she's gonna call me so you have to make it simple Shawn's mom test like well I missed EQ super key like with text messages she'll write like a whole paragraph like love mom that's but slight two-engine so you have to make it past the Sean's mom test it's like first it has to be easy to use and then you have to adapt it so the the myth of our underserved populations using technology is bit by bit going away I think that's something that early on a tomorrow we got more of like oh my you know my Medicaid patients aren't using tech or my god if you looked at a Pew report like every year of year increasing mobile adoption in all walks of life so if you build it to adapt it can work better so we have a low literature curriculum we've specially trained health coaches but we have special content modules for underserved you know we give them special support an onboarding to make sure they understand how to set up the accounts and get kind of going to start and that's an extra investment and the outcomes are good it's it's a little bit harder a little bit but not not to a level where we go to a Medicaid planning director and they're not like this is amazing terrific so it's but you have to push and and we will we will continue to work to innovate in that space because you if you are making you know household 20k or you are up against so many headwinds that that we could potentially help with that it feels like there's the constant opportunity on the table Josh the same question in a different population these are people already affected by diabetes can you comment on the differential enrollment of let's say african-american or mexican-american populations and outcomes in those groups and how I suspect they're different how you would how you go about improving the outcomes in those groups yeah I think so in info the scores are from we launched in January and we have various groups who are on our program we haven't cut it but specifically by socioeconomic status but what we do find is it's more a question of reimbursement and what hurdles you have to get through for that so I think we you know you have a couple progressive Medicare Advantage programs that are reimbursing digital but on a whole it's you know I think digital is held to very different standard than traditional medicine because of the fact that it's it's a new medium what's interesting though and I always think about this is when I was a practicing physician nobody ever said to me what's your quality and will I give you a contract because you're a high or low quality doctor they said okay you have an MD I'm gonna give you a contract no right any doctor in this country any doctor in this country could could bill for pre-diabetes education sean has 11 studies 12 studies and he's still we're still pushing for reimbursement and so we find right now four percent of the patients are our users or 60 or over and they get some of the greatest results so when it comes to these groups digital is definitely a medium they want you do have to adapt for some population so in a medicaid population because data that a lot of people don't are paying for data data becomes an issue when you're using digital programs but they are people with diabetes I'm just like anybody else with diabetes and you have to try to meet them where they're at in terms of you know you can't maybe give them a whole foods grocery last year we news they live in but they have the same needs they interface with the same mediums and they get as good if not better outcomes than a different population mark one of the things that is notable about the Cleveland Clinic is that the extent to which it's acted as an anchor institution in Cleveland yeah with this employer I know not only the biggest employer but you know they've got a hydroponic garden they've got a laundry that serves the hospital they've got a business to business venture in the community that's to me an outstanding kind of investment of the hospital and the clinic is that how I don't know how you're I'm sure familiar with that and probably behind some of it how can you scale that I mean being involved in the community I mean I think that there's a huge effort now to rethink how we connect with the community there's a new Institute that was established in January called Cleveland Clinic Community Care you might comment on that surround the clinic or the community that surrounds the clinic I mean it's tough I mean it used to not be safe for doctors and nurses and to have to walk outside around the clinic you know to lead to go to their car that's improved but it's rough neighborhoods it's neighborhoods you would lock your doors and be scared to go and burn out houses it's it's pretty rough and it's a very poor community and and so they they really are trying to rethink how we how we engage with the communities it's tough I mean there's a non-profit a desk 200 us five percent of its profit into the community but that's the community benefit initiatives yeah yeah and and I think they're trying to reimagine how to do that and it's it's hard because I think as a there's a lot of feel-good projects but the question is how do you rethink care delivery to go beyond the walls of the hospital clinic and that's what we're trying to reimagine now because that's where the solution whether it's digital solutions but there's community-based solutions I just was in a session yesterday where there was a report on the I think ten billion dollars that Medicare and the Center for Medicare Medicaid Innovation Fund is deploying to try to create models of innovation and the only thing that was effective was community health workers it was are the most effective was kamini health workers which was not surprising to me and I think you know I said to the CFO we need a higher 10,000 community health workers at Cleveland Clinic and he laughed at me but I'm like I said that's who need to go and I feel like you know is such a tough problem because you know Paul Farmer talks about structural violence in order the social economic and political ignitions that drive disease and then if you focus on the medical side you're missing all of that and we have a food system that's driving disease we have policies which we'll get into that are driving disease we have you know targeting of the food industry to poor and minorities deliberately we've got a number of FOIA requests out that we've gotten documentation of their behavior which is kind of shocking and how they you know they fund to n-double-a-cp they fund Hispanic Federation they fund hunger Hunger groups and I think they're they're trying to control the changes in policy whether it's taxation and and and the changing that those issues that are driving disease structurally in our society have to be done because this is our biggest problem you know we talk about all kinds of issues but this this discourse is really absent in the political conversation which is shocking to me because when you look at the numbers and the costs and the that productivity losses and the competitive losses the national security issues and the climate changing environmental issues the challenge of kids learning and even it linked to poverty and violence you know you look at studies in prisons where they give violent prisoners healthy diet reducing violent crime in prisons by 56% they had a multivitamin reused by 80% so what are the implications for that of keeping these communities poor this vicious cycle so we have to address that and I think Cleveland Clinic is really taking steps to do that but it's it's tough to to reframe the concept of what the role of healthcare system does and it's not just episodic care it's really changing and the changed in ACA and the accountable care and value-based reimbursements will start to shift that but they don't know what they're doing oh right it's the transition from sick care to health care yeah and it's challenging because doctors are so in their model of treatment of disease and episodic care so you don't have to think about gee maybe we need to build community models and we need to hire 10,000 health coaches and people that cook could shop and build communities and groups and yeah right oh that's a question i mean i i'd love to know what is the Cleveland Clinic's appetite for working with philanthropists you know you have so many amazingly committed people in Google and I mean we're in the Bay Area it is is crazy the amount of wealth creation yeah any amount of inequity and I don't know if you think that's what you're good at as the Cleveland Clinic but I would really urge you to think more about that yeah you know as Hyman em at CCF depression that you said 10,000 health care you know community workers kind of jokingly like that will never happen yeah but I mean the amount that we are investing or spending I mean the upper most costly 1% of people with diabetes in the United States it's it's $100,000 a year times 200,000 people that's 20 billion dollars the upper 1/10 of 1% and you have many of them yeah sorry I mean but you do in Cleveland you know the the that is there have been seven million dollars here times 20,000 that's another 20 billion can't we take that and invest that in what Shawn is doing and what Josh is doing and what verda is doing and what your CEO I guess doesn't want to think about is hiring 10,000 community health care workers like why do we think that's the only thing that's effective because we can communicate with them as patients you know it's an investment not a cost so I think him simple anthropos and you're urging that would be yeah we are anniversary patient communities we are especially the patient communities that you're talking about no we have a proposal for the for the food pharmacy which is you know two-year study rigorously collecting data and and just on that like making sure you're learning from Geisinger you're learning from zuckerberg general you know there are some places that have done it so anyway I'm hearing that sorry to get too excited about philanthropists yeah really quick just just a really quick on to follow up on that so I'll just take a chance to put it in a plug for other Milken Institute research by Marlon Graff who's here in the room and another colleague of ours and so that it shows on community health workers that the increased ratio of community health workers to population if you compare across States is very significantly associated with with better health outcomes and access you know care increased life expectancy in particularly so anyway that's available on our website as well but it there is there and they live looked also what other evidence of the effectiveness but there's no we have a reimbursement problem we really have evidence-based medicine we have reimbursement based medicine that's a problem exactly that's the issue to be clear though it's I don't think it's for a lack of understanding it's not for a lack of efforts I think it's a lack of reimbursement and the lack of a basically publicity and an awareness so my guess is almost every single person who has insurance has some program available to them for pre-diabetes or weight loss or but nobody knows about it because that's not what the health plans are promoting and it's not because we don't have public awareness the science is there right we understand a lot of the biology we understand some of the physiology we're getting a lot better on the pharmacology but still it's access and it's getting paid for that right agreed so let's one of them I want to move on to policy but start with payment policies related to your two programs and and I think I still have this right that the CDC has provided certification to providers in the DPP in a community-based program but not a did what not a digital program is that correct that's correct okay and and CMS likewise has will pay for that will pay for a provider but also not for a digital program is that also true so how do where do we need to intervene for that is that at the level of I mean you know having been at the CDC I know how right a little complicated that is but why don't but I'd be interested in where you think that change has to occur because if you're gonna open up a gala belushin how do you pay for it it's yeah I mean this is it will be a mental model shift in paradigm Sifl I think the when tech entrepreneurs come into Omata and they're thinking about a digital health you know offering her company but I always remind them is like look digital health is still the underdog yeah and there's no shortcuts here like I think you just have to have a commitment to research published evidence just continue to like and bit by bit you'll kind of shift and point the world to a different place and that's what we've been doing as it relates to this medical benefit I mean Amadas put forward and invested in a year-long clinical trial in Medicare Advantage patients that we've published an amazing outcomes we just published a paper comparing us that the VA ran against brick-and-mortar programs to try to show equivalents that look look this is delivering the same outcome that you might care about or you've associated value with but at scale we are the first to say don't even pay us if it doesn't work on our commercial contracts we charge on percent weight loss outcomes so we don't make profit unless we're getting to people outcomes that matter and you know we hope if we just continue to say that and say that and say that and say that and and don't don't let off the gas there we will get there in time because it needs to happen and it needs to happen particularly in the Medicare diabetes prevention benefit because right now that is shaped to just in person programs in the spirit of what I said first digital matters a lot when you're talking about long-term engagement and longitudinal touch points and there is savings to be left on the table there's an enormous health impact to be left on the table I think as we start to count and look at the metrics behind the Medicare diabetes prevention benefit um we will see that in order to really fulfill the promise and dream digital needs to be it has to be part of the solution but it's it's a constant dialogue so I assume that you're in you and Josh are in constant discussions with CMS is that right Josh is it the same problem no it's the exact same problem but but I think there's there's actually one there's one level of detail though that I think is really important and it's it's a question of selection and selection bias so one of the one of the challenges that CMS puts forward and I think this is really valid is if you're a digital program and you mark it digitally and you go through the you know you're on Google you're trying to find them on Facebook you get a natural selection of the people that sign up I think there is a role for the referral patterns whether it's coming through their guys in jurors or the physician's office where they'll help select people that actually truly need the program as opposed to people that want the program and we make ourselves available to the want but we also have to figure out how to get to the need and I don't one of the questions that we hear from government is it's not really a question of effectiveness but it's of are you getting it to the right people and one of the things that that you know is relatively reasonable through the primary care to the specialty network is they'll only refer technically the people who truly truly need a specialist one of the challenges that I'd put on my company is and I saw this when I ran benefits for target I saw it when I ran wellness for Optim is you know five to seven percent of people will do whatever you offer them and we'll wheat what Sean and I have to do is prove that we're not just getting the 5 or 10% that are gonna raise their hand and do it but we're getting the 10 or 15% that you truly really need it and and and and so when it comes to CMS at least what I'm hearing is it's not just question of is it effective but are you getting it onto the right people so let's go to this broader question of how do we what are what are the kind of innovative or scalable programs that will take care of the progression of pre-diabetes to diabetes or even mitigate diabetes and those who have it what are the policy solutions that and I think we're now talking about population wide Markey began this and then we'll turn to Kelly I mean III think it's a complex issue and multiple solutions but I think the the concern I have is is we have to have the right solution and the science has to match what we're offering people to get people better and you know I know Shawn and I talked at the Arabians company they were using the DPP trial and the diet-related there because it was proven in evidence but it also was based on old outdated research on nutrition which was saying that low-fat diet was the dye that would fix it we know that's not true anymore Verta health for example as a scalable platform that's used coaching and support for very sick overweight diabetic patients using a ketogenic diet and has 60% of the diabetes reversed in a year they have two year data which is showing this consistent outcomes they had a hundred percent off oral hypoglycemics 94 percent reduced her off insulin an average of twelve percent weight loss which is outstanding and and and so that we have to get really the the IP right of what to do to change biology but then we have to look how is that scalable yeah this is scaleable digital solution Oh digital it's a digital solution so they have multiple touchpoints with the coach they get all their biometrics they measure the ketones and they have 83% adherence at a year measured by ketones that are digitally transmitted so that there's solutions that I think are digital that are scalable and then are able to be reaching a lot of people that should be reimbursed that's a key policy change but I think the bigger policy changes what is the environment that we can influence by changing the food policy in this country and I think you know I was just in Abu Dhabi and the the head of the Mabon of fun which is the sovereign wealth fund basically said they put in a 50% soda tax in 100 100% energy drink tax and they had a 50% reduction in soda consumption a 70% reduction in energy drink tax that's just one idea but there are many things looking at like you said stop subsidizing commodities subsidized specialty crops which are 1% of our subsidies which is fruits and vegetables you know and you know taxation issues looking at mark food marketing the kids I think it's a huge issue we've got massive marketing and in in Chile they actually found that by ending marketing to kids they dramatically reduced consumption and food patterns you know well they didn't actually change marketing kids they changed the the logos so Tony the Tiger no longer supports prospered place right Tony Tigers dead right no but they did did a lot vert izing directed at kids from between 6:00 in the morning and 10:00 at night and and so you see you know there are scale of policies that can be done but the political will for that is really tough and I you know there's so many opposition forces in the food industry that makes it really challenging I realize some of those companies may be in the room but that's that's a huge challenge and we have to rethink our food system I think big food companies are doing that Pepsi is doing it Ness is doing it Mars doing their create a new sustainable coalition for thinking rethinking food it's fascinating to see how the consumer demand is actually driving their behavior but those those have to change so we have to reimburse the right things and we have to we have to actually change the food environment through multiple strategies policy strands policy strategies yeah so Kelly yeah and this is so interesting I loved what you were saying before about just the combo genic environment because there is a lot that could happen on policy and also I I think there's a lot that can happen with employers and there's a lot you know even like Aetna you know the former CEO and Mark Bertolini you know many of us probably know him as really a hero he's coming out with a new book April 9th I'm talking about his his his mission driven leadership and about how the employees want this where he works and I do think as the you know it's Jens II now that we're hiring coming right out of college I think they're demanding it it's not it's not yeah it's full employment in San Francisco New York Boston etc but it's maybe not be full employment everywhere but they are demanding this and so I think not only looking to what can happen on the policy level but looking to employers and citizens to drive the policy you know to have citizens asking for I think a lot of citizens have no idea that we're subsidizing corn you know they have no idea that it is so hard to get to patients all of that so that's my favorite policy idea what is eliminate the subsidy the idea eliminate the by city and and also prompt prompt subsidies in fruits and vegetables and I know it's complicated it's not as simple as it sounds but it must be possible to have people eat healthier I mean and also look at CVS I mean they got rid of all tobacco that was two billion dollars off the top line maybe they're not going to get rid of all junk food all soda but if we look at snap I mean what what is the single you know biggest use of snap dollars its soda yeah I mean clearly clinic got rid of all sugars Hospital yes but I'd love to know what you would love to see well I'm I'm happy to share that but I'm just as interested in what the rest of our panel will say I mean because you two guys are in the technology space but surely you think outside of that or think about how to expand technologic solutions to the entire population I'd be interested in your thoughts I mean my our mindset in a bit of my mindset has been all right we need to create an environment where people have a group setting a coach like we almost need to create a little shell around them to protect them from all the horrible influences out there in the world like it's like I would love I would love for me to personally feel like actually it's helpful like the environment that climate the Food Policy the the food climate we all live in is actually an additive to a program because right now it's not an additive to the permit that would be an amazing world to get to and I think would further our outcomes and bill to have impact and I think so I think it can't happen in the other like one just interesting thing on demand so now I was a couple of months ago sitting down with the CEO of a very large Japanese you know beverage company and what he was sharing it's like look we're really interested in healthy drinks and this is because as the population has aged there's more anxiety and worries about Alzheimer's cognitive decline and that is becoming viewed as associated with sort of sugar sweetened beverages and they're feeling a huge pull to launch health forward drinks and like that's a beautiful thing to hear so it's like I think it'll be a little bit of a push poll that can get us there yeah Josh yeah I agree with everyone but I I think this focus on food is a little bit misguided because there's a lot of people who are overweight even obese who are metabolically healthy because they're exercising and because there are quite a few there are um but so so sure that we could transform food in the country which would be great but I'd rather see transform physical fitness and movement kids don't play anymore you don't see kids out on the weekends there's schools that cancel gym and I'm not talking running marathons I'm talking moving and yes I'd love to see food reform but more importantly I'd love to see exercise but every kid should be exercising 60 minutes a day six days a week so some of the encouragement everything we like right but so I you know I think it's Josh I think you're correct that there have been just as substantial declines in the calories spent on physical activity as there have been on the increase in the calories spent on food and I think that there's been a disproportionate emphasis on on food certainly if you're not by the food industry they don't know but if you're talking about prevention there's an equal case to be made for physical activity and yeah yeah they're talking about treatment physical activity reduces comorbidities but doesn't help people lose weight realities you have to run for miles to burn off one soda used to run four miles every day for a week to burn off one super-sized meal you can't unring outrun a bad diet absolutely totally agree with that so food is one aspect of it but the problem with it but even the way we're talking about it so paternalistic let's just not make sodas available to people well there's actually there is human choice in this right and there is human behavior and and there are people that will pay that $12 a soda because there's still people who smoke but I do think that the the single pronged approach of let's just you know address food it's not gonna solve it what we saw with tobacco industry was actually really good massive public awareness campaigns taxation free smoke cessation programs education and the school systems and trying to prevent people from starting like there is no silver bullet in this and to say oh it's food taxes well no it's Mulkey what so so we have we have three minutes left and I'd like to hear from each of you one sentence about the highest priority this isn't the sentence can go on for a while there's a lot of commas in you the most important thing commas in there and then before I get to the final period right right away so for me it did all of what has been said here is incredibly violent but it it is a multi sectoral approach involving many different parts of society and we haven't you know we haven't had a chance to touch on some of the innovations that could be done in schools to reduce the childhood obesity epidemic in the building infrastructure bike paths and currently there's there's so many different ways to get at this I think there was a period there thank you try to do this all right if the acceleration of reimbursement coverage on the commercial side was mirrored by commercial reimbursement on the private side and Omata ended up in a world where we were covered by all I can all but promised you we would find a way because it would be sustaining for the company to get people in the door from multiple referral sites with plenty of demand to reduce incidents of obesity related chronic diseases cool yeah good I think listening to patients and caregivers and families about what they need recognizing that these are progressive conditions pre-diabetes is progressive type 2 diabetes is progressive looking at it from a multi-stakeholder perspective and encouraging investment on therapy cardioprotective renal protective encouraging therapy on what's easy-to-use making the healthy choice and encouraging investment and listening more to you and I hope you're going to give us a paragraph yeah be short I I think the the key things that could really move the needle are changing reimbursement for food as medicine and for community-based solutions like these guys are doing or other kinds of community-based solutions I think those are the biggest levers to change behavior which is changing the money flow perfect I'd say universal access and coverage because once you could do that you really can do population health when it's still just for a narrow population you can't solve the problem for the country right so Kelly's been pushing me on a concluding comment and you know I think that these these type of mass problems are not going to be solved at the federal level not in they've certainly even with the Obama administration's massive push on this we made progress but we didn't solve the problem maybe you could argue that we did reduce obesity in two to five year olds as a result of the changes in the WIC package we flattened the prevalence in six to eleven year olds but I think that that if social change around these issues is going to occur it's going to begin at the community or the state level not at the federal level and that it's going to take as I think you pointed out Kelly a cross-sectoral initiative that's and how one achieves that through a focus on obesity I'm not sure that is the focus I think it's still people still view that as a cosmetic problem rather than the medical problem and whereas diabetes may be a much more cogent area for engagement so join me in thanking this panel it's been a great [Applause]

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