In this episode, host Christopher Habig engages in a thought-provoking conversation with Dr. Andrea Feigl, an expert in global health and an economist. The episode offers a unique perspective on the global healthcare landscape, chronic disease management, and the role of healthcare providers and patients in creating better health.

The impact of chronic diseases on both health and wealth, in the United States and emerging economies, is explored, with shocking statistics on their economic burden. Dr. Feigl emphasizes the importance of intervening early and presents a win-win-win scenario for public-private financing partnerships in healthcare.

The concept of investing in primary care is highlighted as a sound strategy, especially when considering the economic and health impacts. The episode also provides insights into different healthcare systems, drawing from Dr. Feigl's experiences in Austria and the United States, emphasizing the vital role of primary care and the need for aligning incentives to promote better health.

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[INTRODUCTION]

[EPISODE]

One of the topics that I don't think we pay enough attention to, and I jokingly refer to as an unwanted roommate in many people's lives, are chronic diseases, or non-communicable diseases, things that we just accept as we get older that, “Oh, I'm going to have diabetes, or I'm going to have hypertension, or I'm going to have whatever, insert problem, heart issues, whatever it is.” We just sweep it under the rug as a society and don't focus on the massive toll that it takes on dollars, time, and lives.

Today's guest is somebody who has dedicated her professional life to chronic illness and helping bridge funding gaps and help bring solutions to those patients affected with these types of diseases. A truly global citizen. Please welcome Andrea Feigl with the Health Finance Institute. Andrea is the CEO and founder over there, which is a high-impact, evidence-based investment foundation that help prevent, treat, and manage chronic conditions. In all of her spare time, she's also an associate professor of health finance at the wonderful Georgetown University. Andrea, thanks for joining us here on Healthcare Americana.

You're in Washington DC now with the Health Finance Institute. Really, my first question right out of the gates is, what is the Health Finance Institute doing when it comes to non-communicable diseases and chronic conditions for a global citizen?

Just to share some numbers, about 4% to 5% of GDP are impacted in emerging economies, because we don't act early enough and we don't act on the best evidence. In the US, the mismanagement of chronic conditions of people getting too sick, people not accessing the health care systems, not having the right prevention and primary care access that they need, it costs us an effective 9% tax in taxes. The equivalent of 9% in taxes.

Imagine, you go and ask a random person on the street and say, what if we taxed your income an extra 9%? Everybody would be up in arms, right? We're accepting this reality, because it's this slow-moving tsunami that we're like – it's not like a pandemic where yesterday we were fine and today, we have to mask up and stay indoors. It's something that just slowly develops, and we've become used to it. We really focus on making the economic argument and helping public-private financing partnerships to address this issue. Because if we come in and intervene early, we can actually save the health of people, we can save the healthcare system money and we actually can help the economy grow faster. It's a win-win-win scenario that we're trying to promote with our work.

I think, all too often, we as Americans, we get our blinders on and think that the good, old US of A is the only really thing out there that matters. We lose sight of what is happening globally. Chronic diseases isn't just a bona fide United States problem. Chronic diseases are running rampant across the human population.

50% of childhood cancers in emerging economies are not diagnosed. Those children die of childhood cancers. They never have a chance of survival, because there is no diagnosis and no treatment for them. Then we have other countries that are a little bit more developed in the least developed countries such as Malaysia, and they are because of a lack of a good primary healthcare system, 60% of people who have diabetes get diagnosed in the emergency room, right?

What does that mean? They come, because they don't feel their limbs, they lose their eyesight. Then often, if these are adults who are providers in their families, their children and most importantly, girls are the first ones to suffer, because the school fees can no longer be paid and it impacts education and the next generation in terms of both of wealth and everything else.

It's again, it's not like a pathogen that travels on planes, but there is a connectivity in terms of the economy and trading partners and just from a human rights perspective, right? As well, in terms of making sure that people have fair innings when it comes to their health status and what they want to achieve.

You mentioned a couple times that access and really putting the emphasis on primary care is a solution forward. Has that been the best way forward that you have seen and your work has seen that says, establish primary care, get people boots on the ground, and then that's where we can start making a difference?

Again, you start treatment journeys early. Whether it's cancer, or whether it's diabetes, or anything else, you're really – the cost versus burden is really favorable towards lower costs and lower disease burden. Now, the interesting thing is that 90% of health is actually not generated in the healthcare system. We have healthcare systems that are primarily reactive. One can argue whether a primary healthcare is reactive or proactive. We want to have a proactive and accompanying primary healthcare system. I think you mentioned that your platform has this model where the patient is not alone on the journey. The person is not alone in their journey.

Whether we see it with, there's something called directly observed treatment therapy when it comes to tuberculosis patients taking their drugs to that system, that model applied in HIV, to that model applied in chronic disease care, it works and has benefits. It has benefits, again, at the health, economic, and the cost front, right, but we are not applying it well enough.

In terms of the lifestyle choices, or the lifestyle in general, it is a very, very complex issue. As I'm sure you know as well, and probably a lot of the viewers, or the listenership knows as well that the food that is avail – the food choices that you make, everything from the school cafeteria to the types of grocery stores you have available, to the walkable score in the walkability score, or walking score of your neighborhood, to availability of public transportation, sports programs, and so on, their equity and equality, or inequality are huge issues playing into that, that one can also not take away from that equation.

Because ideally, we want to prevent people from getting sick in the first place, and then we want to keep people as healthy for as long as possible. But primary care versus investment in tertiary care infrastructure, for both the disease management perspective and the fiscal management perspective is definitely a very sound strategy.

I'm like, you know, what if they just said, well, soft drinks are no longer legal? Cheetos, Oreos. Pick on the big ones like that that are historically, these are the foods that are in food deserts. This is where EBT dollars go to for the lowest rungs of socioeconomic ladder. Those are real lasting change, but I hope there's no flashing red lights underneath my truck after this episode gets released.

Ultra-processed foods, such as the ones that you mentioned, have an outsized impact on obesity, on diabetes, and those externalities. The health conditions that they create, so. both the human suffering and the financial implications are not integrated. It's the same as the big polluters. They weren't actually, until we have carbon taxes and carbon emission limits, they weren't held accountable for all the ill that it calls. Right now, we're not – apart from having something like, sugar sweetened beverage, or health taxes, which California has, and it's almost a one-to-one relationship for each percent of tax that you apply to sugar sweetened beverages, you have a 1% decrease in obesity rates in these types of settings, where this is being applied.

In the US, we talked about some developing countries that are having trouble accessing physicians. Now, growing up in Austria and European health systems, very different than what we have in the US and very different amongst each other. What are your insights that you would like to share with us about really the system that you spent your first 17 years your life experiencing in Austria?

Fast forward, they both got diagnosed with diabetes. It was the fact that they all of a sudden had to now limit those foods that were a symbol of the wealth that they came into after living through both World Wars was really difficult for them. Our family doctor hated a house visit. We used to have house visits. They came once a week. Two days before the doctor came, well, guess how good their diet was? Very good. I remember, but the relationship with the care provider, they would always – doctors were very well regarded in in those little villages that I grew up in. They always got a little bit extra, right? They got some eggs from the chicken.

I remember this picture of our family doctor climbing the cherry tree off my great grandmother's house, picking the cherries to take home for his wife to bake a cake with. I think we would be hard pressed to find that patient-physician relationship in the American context. I can talk a little bit more about the financing and the thing is that we have compulsory health insurance and it goes through sickness funds. The physicians are contacted in the private sector. Of course, they think and probably are underpaid compared to the American physician. There is a two-tiered system with an additional private healthcare insurance.

Yes, the wait times are shorter there. It's not perfect. But there has never been in the history of me in a system, a situation where I'm like, I need care and I don't get it. And an interaction with my primary care physician, where I didn't feel that he was invested in my health and where I didn't feel personally encouraged to basically keep working to whatever health goal there may have been. Of course, we have high chronic disease. We have chronic conditions, mental health care could be better. But that interface between the family physician and the potentially chronic disease patient is much stronger than it is in the United States.

We're not investing enough time and energy and money really into primary care. Our medical students come out and there's active – there's medical schools across the country who say, “Oh, well. If you go to Vanderbilt University, in medical school, we don't make primary care doctors here.” This is just like stigma against primary care in the US, mostly based on money and based on the hours. Our primary care docs are the ones that actually want to be involved in the community and want to go out and do right by them, but the payment system is so broken. I think that's what most people, when you boil down problems with US is that, why are we throwing some arbitrary card in and expecting that to be covering it, and we can walk into a doctor and just say, “Hey, go ahead and fix us,” without paying attention to the problems and what cause the problems in the first place.

It's so fascinating. From your experience in detailing international systems, that they're all a little bit different. Yet, we walk in thinking, “Oh, well. Our doctor can go fix anything we do. Then we don't have to listen to them, because we're going to have some miracle pill when you walk in a few months, if necessary.”

Now, back to your issue around primary care and access. I just wanted to say two things. I think the notion of task shifting, and I think the US is actually doing a good job in terms of nurse practitioners and things like that. I think task shifting and I think also, digital platforms can actually play a big role, and the incentivization of staying healthy. Really making this incentivization a bit more precise. You talk a little bit about concierge, or precision medicine. For example, I'm with United Healthcare and then they offer me, I don't know, a $20 gift card at the end of the month, if I stick to certain things. I'm a fairly healthy individual. I'm like, well, I shouldn't be offered the same incentives as somebody who is completely on a – might already be overweight, might be older, might be a smoker and things like that. I think we can do a lot there.

I think that connection between those systems, both health and employer systems that generate, or support the well-being of the populations that they interact with should be benefiting from that. In the UK, primary care doctors that had fewer referrals to specialists would actually get compensated if they were able to manage their patient contingents with chronic conditions better. Basically, if they could keep diabetics with regulated blood sugar for an HBA1C levels for a longer time and not refer them out to an endocrinologist or other specialist, they would actually personally financially benefit from that. Obviously, the patient would benefit from that, too.

Once people hit the age 65 in the US, employers ensures that communities that contributed to healthier populations get no benefit from that, right? There are ways of aligning incentives within insurance systems, within large employers. Even, I think, at the compensation level through these innovative structures. This is what we're working with in our organization saying, well, better health will benefit everyone in terms of productivity, in terms of health outcomes, in terms of costs incurred to the system. But you need to buy in from the politicians, you need to buy in from companies, and you need to create the right environment for individuals. Because I think nobody wants to be sick, and this is also our logo, right? NCDs, Nobody Chooses Disease.

Maybe for some crazy fringe groups out there, I think the statement can be universally applied. We probably won't have time to talk about this, but there are incentive structures for insurances, and for payers to actually make sure that providers and patients are benefiting from creating better health, rather than from just providing more treatment.

I love your quick, shallow dive into Medicare there, that you're absolutely right. People think that once I hit 65, hey, I'm on easy street right now. They don't realize that this is a government bare minimum program that is not tailored to what they need. You're exactly right. Whether you're a train wreck, or you're somebody who's really taking care of themselves, you're not rewarded for that whatsoever. You're actually penalized the longer you stay on your employer program, or your self-funded program, you're penalized for not joining Medicare. It's so bizarre.

In my world, we have all of our doctors opt out of Medicare, so they don't participate in, whatsoever. Because we have so many doctors that actually do house calls and that do pro bono care. The way that those Medicare regulations are written right now, if our doctors charge a Medicare patient less than what Medicare reimburses, that's considered Medicare fraud. It's just like, why are we disincentivizing people from acting like human beings and taking care of their fellow neighbors? Incentives are a big part of our world and a big part, I believe, of the solution.

Andrea, we're going to take a quick break. We're going to hear from one of our great sponsors, FreedomDoc. After that, I do want to dive into really your background and your motivations, because what you've done here is really set out to tackle a very large, very expansive task. I want to dive into really, why you woke up one day and said, “Hey, this is what I want to go do.” First, a quick message from our sponsor, FreedomDoc.

[MESSAGE]

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[INTERVIEW CONTINUED]

I was also very interested in medical science. I meandered a little bit. I started out in undergraduate, studying biochemistry. Was doing a lot of bench job research and looking at protein folding and add my favorite protein. I was the only girl in a lab with 17 other male scientists. It takes a long time to study things. I realized that was not my best conduit of change.

I stumbled into public health when I was in my early 20s and fell absolutely in love with a reading list of the master’s program and also, my mentors there. One of the first books that we read was a book named Pathologies of Power by the late Paul Farmer. He basically promoted the notion that no matter whether you're poor or rich, you should have the access to the best health care possible. Just because you're poor, doesn't mean you should be condemned to having second, or third-rate care. That message really resonated with me.

I was really inspired also by the ability of policy to make changes in people's lives. I was an international student in Canada, and we didn't have a good health insurance and we didn't have dental insurance. Our student president implemented this policy that we had access to dental care, and it made a huge difference to me personally, but also, to the whole student body. Instead of that one-on-one model of medical care when you're a physician, I really felt that my calling was in international policy.

I was very fortunate to always have very good – studying was easy for me. Doing economics and health economics was something I felt I could become good in, so I felt that was an area where I wanted to basically, apply myself and look at some of the big issues. Then I had the great opportunity to work with mentors at the World Health Organization and the Center for Global Development and with some of my professors at Harvard who are really leading scholars when it comes to chronic diseases, chronic disease management, measuring health states and looking at the economic burden of diseases.

Looking back, those five years have been hard and because it's not easy to fight that elephant in the room of chronic diseases and chronic disease financing, but at least we're trying to make a difference, as opposed to just keep pushing out numbers as important as they are. If they're not applied, then, you know.

But if people establish relationship with a doctor and they establish trust, they will listen to that person, and they will listen to that person when they tell them to go get a test on at this place, or go get a surgery done here. There's a lot of care navigation and a lot of, I guess, cost savings and a lot of education that happened in primary care. Point is, even our deeply divided Senate agrees that primary care is vastly needed, whether they disagree and I think that's your point is, who pays for it? That's the big thing, right?

What you just said was yes, this is a society problem. This is a global problem. How do we get to invest in one another? Then on the micro level, if I'm sitting here saying, “Wow, I'm investing in our society's health, just the same as that guy over there and that guy smoking 15 packs of cigarettes a day and drinking three bottles of booze, what is going on here? Why am I being punished for his unhealthy habits?” That's where a lot of the disconnect happens on ground level.

I don't know how to how to solve for that one, especially with the ACA now, where everybody's in it together, rather than penalizing the people who run healthy. But the flip side to what you were saying is, how do we increase access? You mentioned Paul Farmer and he's a subject of a phenomenal book called Mountains Beyond Mountains, details his story going through here. That was an early, I don't know, wake up call for me? I'm the son of two physicians here in the Midwest. I thought, community doctors and walking to restaurants and everybody know who you were. I thought that's what all doctors did. Very naive of me, I guess, as I grew up and realized that wow, the more we commoditized doctors, the more money we put into hospitals and insurance companies here in this country.

But we're dealing with people that want to help out, right? That's always the big question is how do we get doctors to the point where they are able to see any patients and establish the trust and help those patients out? I'm curious to hear your work through the Health Finance Institute on how you answer that question.

I don't think there's a single healthcare system that gets it all right, but I think it needs to be a mix between understanding where the market can work and where the market doesn't work in this. Where we're saying like, we want to make – in order to widen access, we need to increase the risk pools, we need to increase the pooled resources that we collect and we also need to make sure there is a good distribution of different likelihoods of getting sick. Then you have the ability to negotiate certain conditions that are both favorable to the patient, to the financial well-being of the insurance, as well as those who provide that care and making sure that incentive is actually aligned.

Some ways, there is this emerging field of value-based care, and it's early and not every single value-based care contracting gets it. But it is at least an attempt to say, what are we doing that actually creates value to the patient? Because that usually, then also aligns with the notion of the physician who wants to care and can care. Then also, lowering the administrative burden on the physicians as well, which is again, I think 50%, 60%. I mean, the stats are just absolutely outrageous, right?

If you have a more simplified, better frame contract between these three entities, I think then, you see a better relationship there. I just want to say like, I painted a very rosy picture about Austria, but it's also that a lot of physicians, primary care physicians there are also opting out of the national health care system, because you have almost like, you can have something called death spirals, where you have more and more patients and very limited reimbursements. They say, “Why don't I just go to the private sector?”

This tension between caring for everyone, versus the satisfaction of physicians which is a balance between pay and actually being able to care for the patient is very difficult. I don't have the ready-made answer for you, but we really look at it from not an individual perspective, but also, the contractual perspective at the systems level.

Andrea, last question for you. I want to pull out of health care real quick. I want to switch over to dancing, like we talked about. You're a professional ballet dancer in all your free time, and with your family. I see now that your passions are leading you to the salsa and the Argentine tango. What's your word of advice? What are you trying to tell listeners when they're like, “You know what? I want to get into the salsa. I want to get in the tango. I don't know where to start.” What’s your words of wisdom?

Like takes any anything else, you need to put the time in, right? It's really the amount of time that you spend with a subject matter, whether you practice the piano, or go dancing. You're not going to conquer the world, or the dance floor in the first lesson. It will take a couple of months, so don't be discouraged. I think, there are lots of groups. In DC, for example, we have Capital Tangeros, for example, and there’s events every single night, and there is lessons every single night.

I think that the most important thing is join a community where you feel you fit in and you're welcomed. Also, find a teacher that you feel resonates with your own learning style. Then let the passion carry you forward.

[OUTRO]

[END]