…Build this better version of our healthcare system with expanded access for everyone, not just white (male) patients. All of the solutions listed will be insufficient if we don’t address the growing diversity of the US population and the needs of women. So many of the new virtual care solutions begin as English-only, with limited options for qualified translators or multilingual virtual services, and only in the last five years have we seen innovations designed to address the specific needs of girls and women. This is not surprising, because most health care administrative and clinical leaders are white males, a pattern even more true for technology developers working on digital solutions. But it is also is surprising, because the willingness to use digital technologies is high across cultural and economic groups — for example, 86% of the Latino population have smartphones, and new text-centric solutions in healthcare are extremely successful in reaching and engaging diverse populations across large parts of the U.S. I can only hope that these and similar solutions multiply in healthcare, and attract the attention of technology developers from similarly diverse communities.
As a part of my interview series with leaders in healthcare, I had the pleasure to interview Molly Joel Coye, MD. Molly Joel is on the board of Ginger, an on-demand behavioral health provider, and is also the founder and former CEO of HealthTech, a non-profit center that became the premier U.S. forecasting organization for emerging technologies in healthcare. She’s also served as Chief Innovation Officer for UCLA Health, is currently Executive in Residence at AVIA, on the board of ConsejoSano, and served for 14 years as a member of the board of directors of Aetna, Inc. Dr. Coye was previously the Commissioner of Health for the state of New Jersey and Director of Health Services for the state of California, and as a member of the Institute of Medicine, co-authored the seminal reports To Err is Human and Crossing the Quality Chasm.
Thank you so much for doing this with us Molly! Can you tell us a story about what brought you to this specific career path?
Growing up, I was surrounded the medical world. My father was a doctor and my mother was a mental health social worker, so visiting my father’s pathology laboratory and coming home to intense discussions of how to improve healthcare were just a part of everyday life in my family. Despite this, I didn’t decide to go to medical school until I was 27 years old. I had studied Chinese history at the University of California at Berkeley, and then lived in Taiwan for two years, becoming fluent in Mandarin Chinese. But by the time I returned to the U.S. to finish a master’s degree in Chinese history at Stanford, I had become fascinated by the ways in which innovation and community engagement could drive strong, effective strategies for improving the health of underserved populations. So I decided to turn to medicine and public health, earning my medical degree at Johns Hopkins, together with a master’s degree in public health, in 1977.
Can you share the most interesting story that happened to you since you began leading your company?
The most interesting, intriguing experience for me as a member of the board of Ginger has been learning from their newly published research on the breadth of mental health problems in the U.S. today. In Workforce Attitudes Towards Behavioral Health 2019 Report, Ginger’s findings led with an image that still resounds for me: “48% of American workers report that they have cried at work.” They also found that 83% of workers experience stress in the workplace on a regular basis and 50% are more likely to seek behavioral health help now than they were five years ago. Importantly to me, Ginger worked with an independent research firm to do this survey, using excellent methodologies, and I’m proud to be associated with their quality and commitment to this work.
Can you tell our readers a bit about why you are an authority in the healthcare field?
After receiving my medical degree from John Hopkins in 1977, I’ve worked in a variety of roles that span the healthcare industry — beginning as the youngest Commissioner of Health in the country, then joining the faculty at Johns Hopkins, and later innovating in Medicaid programs and technology development and advising healthcare systems and investors. I’m currently on the board of Ginger and serve as the Executive in Residence at AVIA, the nation’s leading network for health provider systems. Until last year’s acquisition by CVS, I was a member of the board of directors at Aetna, Inc. for 15 years. Prior to that, I held a variety of leadership roles in both the public and private sectors, including Chief Innovation Officer at UCLA Health, Director of the California Department of Health Services, Commissioner of Health for the State of New Jersey, and founder and CEO of HealthTech, the country’s foremost health technology forecasting organization.
What makes your company stand out? Can you share a story?
I believe it’s Ginger’s vision, which is to create a world where mental health is never an obstacle — for anyone. My mother’s career as a social worker drove my passion for democratizing high-quality care and I see Ginger as a company that is taking on this lofty goal for behavioral health. Today, the need for emotional and mental health services has never been greater, and yet the industry struggles to meet that need. Ginger has created a transformative way of providing immediate, high-quality behavioral health support to people, right when they need it, and I’m excited to join their mission.
Can you share with our readers about the innovations that you are bringing to and/or see in the healthcare industry? How do you envision that this might disrupt the status quo? Which “pain point” is this trying to address?
Ginger is innovating in all aspects of access to behavioral health by providing 24/7, on-demand care through behavioral health coaching, video sessions — available within 48 hours — with world-class therapists and psychiatrists, and self-guided content. This immediate access is enormously valuable to our clients, because across the U.S. the average wait time to see a behavioral health provider is 25 days, and appointments are often available only between the hours of 9–5 when most people are at work. Solving the problems of access with immediate, mobile access to care and personal coaching is a transformative approach to behavioral healthcare that is helping thousands of people get better, faster.
What are your “5 Things I Wish Someone Told Me Before I Started” and why? (Please share a story or example for each.)
First of all, always go talk with the people that you hope to serve. Sit down with the patients, their families, and understand how their lives are impacted by illness, by mental health conditions, by the difficult financial costs of care, by the disruption of their lives and the fears and loss of hope that threaten them. As an intern in San Francisco’s public hospital, speaking both Chinese and Spanish, I had to figure out why the care for some patients wasn’t working. I spent hours just listening — and came away profoundly moved in a way that still shapes my work in healthcare.
Second, be bold. As Director of the Department of Health Services in California, I had the opportunity to move the Medicaid program into managed care. At that point we used to say that a Medicaid card was the equivalent of a hunting license — because you couldn’t find an OB willing to deliver a woman on Medicaid. Politically, this was a risk — but advisers urged me to act. I did, and by bundling the care and payment for pregnancy, we transformed lives; all of a sudden the private sector OBs and hospitals were opening their arms and welcoming our beneficiaries.
Third, sadly, be prepared. If you have enough influence to make some of those decisions about access to care and budgets, you will always be misunderstood! When our campaigns to limit smoking in California were successful, this resulted in a decrease in the tobacco tax revenues that we used to support prenatal care and smoking cessation, and I had to make cuts. There were no good answers. The smoking cessation advocates wanted all the cuts to be made in prenatal care — and attacked me for being in the tobacco companies’ pockets! That was very painful.
And fourth, expect and delight in the support and enthusiasm you’ll find in the early stages of developing an innovation. In the late 90’s in Silicon Valley, we developed the first browser-based software for patient self-management of diabetes. We planned for its use in Type II diabetes in adults, but the parents of Type I diabetic children jumped on it and crowded out every other use — they flooded our user groups, helped in each version of improvements, and became our best customers. We’ve found the same enthusiasm from many of the employers and union trusts that have been early adopters of Ginger — and we learn so much from them.
Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high-income nations. This seems shocking. Can you share with us 3 reasons why you think the US is ranked so poorly?
First, for many years, all of the incentives for doctors and hospitals have been to do more — in our largely “fee for service” or “fee for volume” system, this leads to a great deal of waste, unnecessary procedures and interventions, and in some cases injuries or disease caused by this unnecessary care. Solid estimates suggest that more than 30% of care, and thus spending on care, is wasted. The tremendous fragmentation of care in the U.S. also contributes to the frustration of patients (and clinicians), and to repeated tests, imaging, and other forms of waste. Some managed care systems that truly align incentives between insurers and providers, and share clinical information to help patients, have shown an impressive ability to restrain costs, improve outcomes and provide satisfying experiences for patients. We can see this potential reflected in the rapid growth of Medicare Advantage among seniors, as well as other efforts to build value-based care systems such as ACOs and bundled payments, and recent moves by HHS to move primary care towards value-based reimbursement.
Second, we spend almost double what most developed countries do on medical care, and only about half as much on social support — income support, housing, social work, non-institutional mental health, nutrition, and personal assistance. And we get what we pay for: too much medical care, and not enough help to ensure that individuals can stay independent and healthy in their homes and communities. We’re beginning to recognize this pattern, often called “social determinants of health”, but providers and health plans aren’t organized to diagnose or respond to many of these kinds of problems. More importantly, they aren’t paid to solve them — and so the assumption that providers or health plans are going to shoulder responsibility for this may be only a partial solution. Fortunately, digital solutions enable less expensive means of identifying social determinants, and then connecting individuals in need with community resources — and in the case of mental health, connecting them with online coaches and therapists.
And third, we have emphasized curative care — waiting until patients have full-blown diseases, and frequently multiple conditions — over the prevention and early access to care that can keep conditions from growing worse. Access to care is a major challenge for US consumers, even those who have health insurance. In many parts of the U.S., they wait hours in emergency rooms or weeks to months for physician visits and behavioral health therapy. It is no wonder that they are frustrated, frightened and demanding change. While long wait times plague almost all forms of healthcare, these are especially prevalent in behavioral healthcare. More than half of U.S. counties have no mental health providers at all (2016, Health Affairs), and across the US, consumers wait an average of 25 days for an appointment with a behavioral health provider. Long wait times can be excruciating for the consumer and have an impact on the overall economy, with behavioral illnesses, for example, costing US companies $193 billion in lost earnings and productivity. Again, digital innovations can help. Virtual care frees up physicians, nurses, psychologists, psychiatrists, and all our scarce clinicians to spend more time on the 10–20% of us who really need it. With early virtual assessments, we can reduce unnecessary emergency department visits and preventable hospitalizations. We prompt lifestyle changes and preventive care at rates far above current practice. That is why some of these innovations have been first developed in Europe, where national health systems face the challenge of providing care for all under increasing cost pressures, and in the U.S. military and the Veteran’s Administration. I’m delighted that we’re finally seeing these solutions advance in the US, including Ginger’s on-demand behavioral health coaching solution!
You are a “healthcare insider.” Can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
- Our focus has to go beyond insurance coverage to actual access to care — how will we provide it? As the national debate about how to improve American healthcare rolls forward, much of it centers on who will pay, and how consumers will be afforded access to public or private insurance. Under any future system that ensures access to healthcare for all, however, there remains a significant problem of how we can provide that care, conveniently, at a reasonable cost, and with high quality and a satisfying experience of care. My comments focus on this question — how are we going to provide this access to care?
- Move rapidly to adopt digital solutions that expand access. For the last 20 years, my work has focused on the development of IT and telecommunications services — digital health. Our technology and consumer expectations have grown exponentially, and today these innovations offer exciting solutions. Virtual care has gone far beyond simple telemedicine to include mobile coaching and self-management for all chronic diseases, including behavioral health. It costs far less than in-person services from physicians or nurses, and achieves marked improvements in outcomes with much more frequent — even daily — contacts with patients. For poor, elderly patients with diabetes and multiple other chronic conditions, for example, the rate of actually taking their most critical medicines more than doubles in just three months, vastly reducing the use of emergency rooms and hospital stays. A whole year of virtual communications and support costs far less than just one of the emergency room visits it prevents.
- Move rapidly to adopt digital solutions because they also ensure affordability and reduce waste. Virtual care innovations on the market today are growing rapidly and achieving early, very promising savings: text-based primary care is available for $1 per employee per month, in all 50 states, without limit; virtual triage is available free to consumers, at a nominal cost to providers and plans, especially in comparison with the cost of nurse advice lines or emergency department and urgent care visits. E-consults by specialists supporting primary care clinicians cost less than in-person visits to specialists by an order of magnitude, and allow expert guidance without the inconvenience and expense of specialist visits, replacing in person visits by 40–60%.
- Finally realize the national commitment to parity for mental health. The lack of access to care for behavioral health has become a crisis in the U.S. As consumers feel more comfortable seeking care, and providers learn to recognize the symptoms of early conditions, our networks of existing mental health providers are stretched to the breaking point. We can’t possibly provide access for them without the broad deployment of virtual care systems that can triage individuals with severe or complex conditions into direct treatment, and provide coaching and guided self-management for patients with mild and moderate conditions. These virtual care systems offer immediate access in the consumer’s home, community and workplace, recognizing the level of need, and ensuring that coaching, cognitive behavioral therapy and appropriate referrals to virtual counseling and therapy are available within minutes or days, not weeks or months. Recent research from Ginger found that 83% of workers experience stress in the workplace on a regular basis and 48% of people are brought to tears due to work stress — and half also report that they are more likely to seek help now than they were five years ago. This shows that the demand on the consumer side is there, yet access to behavioral healthcare still lags. And in the US healthcare system, the majority of consumers get healthcare coverage through their employer. Because of this, employers have more power to influence access and coverage than they might realize and can play an impactful role by demanding better care for their people. Ginger’s research also showed that workers are looking to their employers to make changes as 91% of U.S. workers believe that their employer should care about their emotional health.
- Build this better version of our healthcare system with expanded access for everyone, not just white (male) patients. All of the solutions listed above will be insufficient if we don’t address the growing diversity of the US population and the needs of women. So many of the new virtual care solutions begin as English-only, with limited options for qualified translators or multilingual virtual services, and only in the last five years have we seen innovations designed to address the specific needs of girls and women. This is not surprising, because most health care administrative and clinical leaders are white males, a pattern even more true for technology developers working on digital solutions. But it is also is surprising, because the willingness to use digital technologies is high across cultural and economic groups — for example, 86% of the Latino population have smartphones, and new text-centric solutions in healthcare are extremely successful in reaching and engaging diverse populations across large parts of the U.S. I can only hope that these and similar solutions multiply in healthcare, and attract the attention of technology developers from similarly diverse communities.
Thank you! It’s great to suggest changes, but what specific steps would need to be taken to implement your ideas? What can individuals, corporations, communities, and leaders do to help?
For each of these changes, there are a number of approaches that can be taken. Here are a few that come to mind for me as a path forward.
- For employers, find out from your employees whether they are actually gaining access to the care they need by regularly auditing the health plans that you offer. The most impactful way to do this is to run anonymous surveys once or twice a year, and to find out not just what services they have used, like EAP, but what that experience was like — how easy it was to access the care, how long it took, and whether they felt it was beneficial. This way you can identify important un-met needs and go into benefits conversations armed with data and direct feedback from your population. You will be able to ask the plans what innovations they are adopting to meet your employees’ needs, or to consider adopting certain innovations and providing them directly.
- At an industry level, investments need to be made in offering virtual care across the board. This will increase access to care across the board, reducing wait times and making sure that consumers get to the right type and level of care on demand. It will increase affordability, and will create more satisfying and efficient systems for consumers, patients, clinicians, and health systems, plans and employers. We can see these patterns emerging, as new types of services are already on the market, with growing acceptance by consumers and providers. Taken together, these innovations will make up the component parts of a new streamlined, responsive, satisfying and high-quality system of care. And unlike telemedicine programs in which the clinician interacts with each patient directly by video, this new generation of innovations leverages clinician time to cover much larger numbers of patients.
- For developers of innovations, find creative ways to scale care, using email consultations, coaching, and self-guided programs. For example, specialist consultations can be accomplished without in-person visits to specialists in roughly half of cases, because a remote exchange of email consultations has been shown to be effective in helping primary care physicians resolve clinical questions. And if, like a large proportion of Americans, you have one or more chronic diseases, including many mild or moderate mental health conditions, an online coach can text with you and introduce you to highly effective virtual guided learning and self-management techniques, or an artificial intelligence-driven nurse assistant can call to check on you and help you stick with the medications, diet and other recommendations from your doctor. Behavioral economics is actually being used very successfully to get patients to take their medications and follow other regimens — so the patients do well and get well.
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
- Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again by Eric Topol — Topol is one of the best-known authors on virtual care and the use of advancing technologies to improve care. In this book, he dives into the rapid evolution of deep learning and the potential to transform every aspect of healthcare.
- Healthcare: An American Sickness by Elizabeth Ronsenthal — For those looking to understand the many nuances of the US healthcare system, such as the different stakeholders, policies, funding, and how institutions operate, Rosenthal’s investigation offers a wealth of insight as well as solutions for the path forward. It’s a great read!
How can our readers follow you on social media?
- LinkedIn: https://www.linkedin.com/in/molly-coye-921a358/
- Twitter: @mjcoye
Thank you so much for these insights! This was so inspiring!